SECTION I

THE NOSE AND PARANASAL SINUSES

J. F. Birrell

CHAPTER 1 ,• ‘
r
ANATOMY AND PHYSIOLOGYff '

THE EXTERNAL NOSE *

i-

The external nose is shaped as a triangular pyranaid with its root above and its
base directed downwards, and perforated by two nostrils or anterior nares,
separated by a median septum. The f^eb angle of the external nose is the apex,
connected to the root by the dorsum, the upper part of which is termed the
bridge. Each side of the external nose ends in a rounded eminence, the ala
nasi, which forms the outer boundary of the nostril or anterior naris. The
skin over the apex of the nose is thick and adherent, and contains many
sebaceous glands. The external framework is osseous and cartilaginous. The
nasal bones form the bridge, and each is united above with the frontal bone
and laterally to the frontal process of the maxilla. Four paired cartilages—^the
lateral, the greater alar, the lesser alar and the vomeronasal—and one
unpaired cartilage—^the septal—complete the externarframework,' and their
inter-relationship is shown in Figs, 1 and 2.
The chief muscles acting upon the external nose are the compressors and
dilators of the ala nasi, and are supplied by the facial nerve. In confirmed
mouth breathers the dilators tend to atrophy from disuse so that the anterior
nares become narrow and slit-like.
Blood supply to the external nose derives from the external maxillary and
ophthalmic arteries, while venous drainage is through the anterior facial and
ophthalmic veins, the latter being a tributary of the cavernous sinus.
Lymphatic drainage follows the anterior facial vein and opens into the
sT^mandibular glands, but other lymphatics drain into the pre-auricular
glands.

THE NASAL VESTIBLfLE

This is the name given to the entrance to the nasal cavity, within the nostrils.
It is lined by skin which contains hair follicles, and it ends at the muco-
cutaneous junction. The part between the two nasal vestibules, containing
the anterior end of the nasal septum, is called the columella.

1
2 THE NOSE AND PARANASAL SINUSES

THE NASAL CAVITY

The lateral wall of each nasal cavity is convoluted in appearance due to the
three conchae or turbinates {Fig. 3). The superior and middle conchae
constitute the medial surface of the lateral mass of the etlmoid bone. The
inferior concha^is a separate bone attached to the maxilla. Each concha*
overhangs a channel or meatus corresponding in length to the concha^
beneath wiiich it is situated. All three reach forwards from the posterior

Fig. 1. The external nose. 1, Nasal bone; 2, Frontal process of maxilla; 3, Lateral cartilage; 4, Cartilage
of septiun; 5, Accessory cartilage; 6, Greater alar cartilage; 7, Lateral^erus; 8, Medial crus.

aperture of the nose, called the posterior naris or choana. The superior
meatus is confined to the posterior third of the lateral wall of the nasal
cavity; the middle meatus runs forward about two-thirds of its length; and
the inferior meatus extends the whole length of the lateral wall of the cavity.
The space above the superior concha is called the spheno-ethmoidal recess.
Between the three conchae and the nasal septum, which separates the two
nasal cavity, is a space called the olfactory cleft.
The meatuses are of clinical importance in respect of their contents. The
nasolacrimal canal opens into the anterior ^d of the inferior meatus.
Communication between the paranasal sinuses and the nasal cavity takes
place through openings, or ostia, in the middle and superior meatuses. The
frontal, anteior ethmoidal and maxillary sinuses open into the middle
 ANATOMY AND PHYSIOLOGY 3

meatus; the posterior ethmoidal sinuses drain into the superior meatus; the
sphenoidal sinus communicates with the spheno-ethmoidal recess. An
appreciation of the detailed structure of the meatuses will be obtained by
studying Fig. 4 in which the middle concha has been removed, and Fig. 5 in
which the superior concha has also been removed.
The nasal septum (Fig. 6) separates the two nasal cavities and is partly
osseous and partly cartilaginous. The perpendicular plate of the ethmoid and

Fig. 2. The external nose. 1, Nasal bone; 2, Frontal process of maxilla; 3, Lateral cartilage; 4, Greater
alar cartilage; 5, Lesser alar cartilages; 6, Fatly tissue of ala nasi.

the yomerjbgne constitutesj^e upper and posterior part, while the septal
cartilage completes the septum anteriorly, stretching from the dorsum of the
nose above to the nasal crests of the maxillary and palatine bones below.
The main arterial supply of the nasal septum arises from the septal branch of
the sphenopalatine artery, and this anastomoses with the greater palatine
artery and septal branches of the superior labial and anterior ethmoidal
arteries at the ^tero-inferior part of the septum^he so-called ‘bleeding area’
or Little’s area, whidBTsr of impm^ahce in qpistois (Fig. 7). The lateral nasal
wall is supplied by lateral branches from these vessels. Venous drainage from
the nasal cavity is throu^ the sphenopalatine foramen to the pterygoid
4 THE NOSE AND PARANASAL SINUSES

plexus, but some veins join the superior ophthalmic vein in the orbit, while
others enter the anterior facial vein. Lymphatic vessels from the anterior part
of the cavity join cutaneous lymphatics to the submandibul^ and so
to the sujperioi^deep ceryic^ glands. Posteriorly the lymphatic drainage is to
the medial deep cervicd glands.
TS nasal mucous membrane consists of a layer of fairly dense connective
tissue containing large blood vessels and some unstriped muscle fibres. There

Fig, 3. Lateral wall of left nasal cavity, showing the conchae or turbinate bodies, the meatuses and
spheno-ethmoidal recess. 1, Right sphenoidal sinus; 2, Sphenoidal ostium; 3, Left sphenoidal sinus; 4,
Superior meatus; 5, Inferior meatvis; 6, Inferior concha; 7, Accessory ostium of maxillary sinus; 8,
Middle concha; 9, Superior concha; 10, Frontal sinus; 11, Ostium of posterior ethmoidal cells; 12,
Spheno-ethmoidal recess.

is erectile tissue comprising irregular thin-walled blood spaces in the anterior

and posterior ends of the inferior concha. A layer of elastic tissue fibres is
present beneath the basement membrane, and this layer allows the mucosa to
return to normal size when the vascular engorgement of the erectile tissue has
worn off. The surface epithelium is columnar ciliated lying upon several
layers of cuboidal cells resting upon the basement membrane. There are many
mucous glands beneath the basement membrane, their ducts penetrating the
monbrane to open on the surface.
There are two nerve supplies to the nasal cavity, sensory and secretory.
The main sensory nerve supply is derived from the maxillary division of the
trigeminal nerve through branches arising in the pterygopalatine ganglion
{Pig. 8). The lateral and medial internal nasal branches of the ophthalmic
nm^ supply the anterior part of the nasal cavity, while the floor and anterior
 ANATOMY AND PHYSIOLOGY 5

end of the inferior concha is served by the anterior dental branch of the
infra-orbital nerve.
Secretory nerve fibres supplying the glands and unstriped muscle belong to
the sympathetic and parasympathetic systems. Sympathetic fibres, which
produce vasoconstriction and diminished secretion, arise from the superior
cervical ganglion via the nerve of the pterygoid canal to the pterygopalatine
ganglion. Parasympathetic fibres, which produce vasodilatation and increased

Fig. 4. Lateral wall of left nasal cavity with the middle concha removed; the lateral wall of the middle
meatus is exposed, and the position of the ostia of the sinuses is indicated by arrows. 1, Right sphenoidal
sinus; 2, Sphenoidal ostium; 3, Left sphenoidal sinus; 4, Superior meatus; 5, Inferior meatus; 6,
Inferior concha; 7, Accessory ostium of maxillary sinus; 8, Uncinate process; 9, Ethmoidal bulla; 10,
Infundibulum or semilunar groove; 11, Nasofrontal duct; 12, Left frontal sinus; 13, Superior concha;
14, Ostium of posterior ethmoidal cells; 15, Spheno-ethmoidal recess.

secretion, are carried in the greater superficial petrosal nerve and the nerve of
the pterygoid canal to the pterygopalatine ganglion from which post-
ganglionic fibres are distributed.
The olfactory nerves—^some twenty filaments—derive from the olfactory
bulb, enter the nasal cavity through the cribriform plate of the ethmoid, and
are distributed in a network in the mucous membrane in the upper third of the
nasal septum and the lateral wall of the nasal cavity. The perineural sheaths of
these filaments communicate directly with the pia-arachnoid and thus may
transmit infection to the meninges.
PHYSIOLOGY OF THE NOSE
The functions of the nose are respiratory and olfactory.
R^piratory. The nose is the normal method of respiration, and a baby born
with an occlusion of both posterior nares makes strenuous efforts at nasal
6 THE NOSE AND PARANASAL SINUSES

Fig. 5. Lateral wall of right nasal cavity with the superior and middle conchae removed; the infundi-
bulum and nasofrontal duct are continuous; the uncinate process has been turned down in order to show
the maxillary sinus ostium. 1, Right frontal sinus; 2, Nasofrontal duct; 3, Ethmoidal bulla; 4, Infun-
dibulum or semilunar groove; 5, Maxillary ostium; 6, Superior meatus; 7, Right sphenoidal sinus; 8,
Spheno-ethmoidal recess; 9, Posterior ethmoidal cells; 10, Anterior ethmoidal cell.

Fig. 6. Left side of the nasal septum, covered with mucous membrane, showing an oblique septal crest
at the junction of the vomer with the cartilage of the septum. 1, Left frontal sinus; 2, Septum of the nose;
3, Kasophaiyngeal cavity; 4,1.^ sphenoidal sinus.
 ANATOMY AND PHYSIOLOGY 7

respiration while keeping the mouth tightly shut. Inspiratory and expiratory
air currents follow similar paths in the nasal cavity. Inspired air enters
through the anterior naris, passes over the anterior end of the inferior concha
2

Fig. 7. Right side of the nasal septum showing the nervous and arterial supply, and the ‘bleeding area*
of the septum anteriorly and inferiorly. 1, Right iong sphenopalatine nerve; 2, Olfactory nerve branches;
3, Medial nasal nerve; 4, Septal posterior nasal artery from sphenopalatine; 5, Anterior and posterior
ethmoidal arteries; 6, Greater palatine artery; 7, Septal branch of superior labial artery.

3 4
Fig. 8. Innervation of the lateral nasal wall. 1, Ganglion (pterygopalatine); 2, 3, Lesser palatine nerves;
4,5, Long sphenopalatine nerve; 6, Lateral internal nasal nerve; 7, Olfactory bulb and nerves; 8, Short
sphenopalatine nerves; 9, Greater palatine nerve.

to meet the anterior end of the middle concha. Here the stream splits, the
main part passing along the middle meatus and the olfactory cleft beside the
middle concha, and the lesser part passing above the middle concha to aerate
the superior meatus and the spheno-ethmoidal recess. The air leaves the nose
8 THE NOSE AND PAJRANASAE SINUSES

over the posterior end of the inferior concha. Little or no air seems to travel
through the inferior meatus. Expired air follows a similar pathway in reverse,
but some of it forms eddies around the middle concha. There is a arhythmic
alternation in the use of either nasal cavity, and both sides are seldom used
equally at the same time.
During its inspiratory passage through the nasal cavity the air is filtered,
warmed and moistened so that, whatever the state of the outside air, it is
delivered through a normal nose to the lungs in a stable condition as regards
warmth and humidity. If a tracheostomy has been performed, thus bypassing
the nasal cavity, the air entering the bronchioles is too cold and too dry,
unless the patient is nursed in an appropriate atmosphere, and the bronchi
respond to this stimulus by producing an excessive secretion of mucus.
Similar, if less dramatic, changes occur in children who adopt mouth
breathing.
Filtration is accomplished by the vibrissae in the nasal vestibule which
enmesh larger particles of fluff and dust, and by the nasal mucous blanket
which covers the mucous membrane and is constantly propelled posteriorly by
the cilia of the lining membrane. This mucous blanket is adhesive, and
bacteria and particles of dust adhere to it. It is also, to some extent, bacterici^l
by virtue of its lysozyme content. Warming of the air is achieved by the
vascular conchae with their submucous blood spaces, and the air is moistened
by absorption of water content from the seromucinous gland secretions.
A nose depends for its health upon the mucous glands and the ciliated
epithelium which keeps the mucus in constant movement. The cilia are robust
enough to function even in infections, but their action is slowed by oily drops
or sprays, and is destroyed by drying. For this reason centrally heated premises
should have the air humidified, and for this reason also surgeons should
respect the integrity of the surface epithelium during operative procedures.
Olfactory. The olfactory sense is less well developed in man than in some of
the lower animals, but it is still sufiScient to allow human beings to perceive
odours in extreme dilution. The acuity varies greatly between individuals.
The direction of the air current ensures that airborne odorous substances
reach the olfactory area, and this is increased by forced inspiration or
sniffing. Olfactory cells are stimulated by these substances, but they may also
be stimulated by the blood stream. In order that an odour may be perceived a
sufficient volume of the air containing the odour must reach the olfactory
area, and the olfactory mechanism must be unimpaired. Thus, nasal conges-
tion or obstruction, as, for example, during the common cold or in the
presence of nasal polypi, diminishes olfactory acuity. Similarly, the effects of
toxins, such as virus infections and certain poisons, may reduce the eflSciency
of the olfactory pathway, while a fracture through the cribriform plate of the
ethmoid will destroy it. The acuity of smell may be estimated by the applica-
tion of varying strengths of different substances, such as volatile oils, to the
nostrils. The olfactory sense is allied to the sense of taste which is also affected
if the former is impaired.

THE PARANASAL SINUSES

The paranasal sinuses, arranged in pairs and in relation to each nasal cavity,
comprise two groups, anterior and posterior. The former includes the
 ANATOMY AND PHYSIOLOGY 9

maxillary sinus, the frontal sinus and the anterior ethmoidal cells, all of which
communicate with the middle meatus. The posterior group consists of the
posterior ethmoidal cells and the sphenoidal sinus Communicating respectively
with the superior meatus and the spheno-ethmoidal recess.
The maxillary, sinus is also known as the maxillary antrum, or, simply, the
antrum. It exists at birth as a small but definite cavity adjacent to the middle
meatus, and it enlarges gradually to reach its maximum dimensions about the
twenty-first year with the eruption of the upper wisdom tooth (Figs. 9, 10).

Fig. 9. Coronal section of the ri^t maxilla
during the period of the first dentition; the
small maxillary sinns lies medially to the infra-
orbital canal; the maxilla consists largely of
cancellous bone. 1, Infra-orbital canal; 2» Right
notaxillary sinus; 3, Second molar tooth.
Fig, 10. Coronal section of the right maxilla of
an adult showing the fully developed maxillary
sinus. The floor of the sinus is on a lower plane
than that of the nasal floor; the molar fang
projects into the cavity of the sinus. 1, Infra-
orbital canal; 2, Right maxiUary sinus; 3, First
molar tooth; 4, Maxillo-ethmoidal cell.

The sinus expands in the maxilla during the eruption of the primary dentition
until it reaches the level of the floor of the nasal cavity about the seventh year.
In adult life it is somewhat pyramidal in shape, its roof being formed by the
floor of the orbit; its floor being in close proximity to the roots of the second
dentition; its posterior wall lying in relation to the infratemporal and
pterygopalatine fossae; its medial wall adjoining the lateral wall of the nasal
cavity; and its anterolateral walls being superficial. The opening into the
middle meatus, the maxillary ostium, is near the upper part of the cavity of the
sinus, and is thus unfavourably placed for drainage. There may be one or
more accessory ostia posterior to the main one.
The frontal sinus is rudimentary at birth, being represented by a small
upward prolongation from the anterior end of the middle meatus, the naso-
frontal duct. During childhood this duct enlarges upwards to reach the level
10 THE NOSE AND PARANASAL SINUSES

of the orbital roof about the ninth year. Thereafter the sinus extends for a
variable distance as a result of absorption of cancellous bone between the
outer and inner tables of the frontal bone. The anterior wall is formed by the
outer table; the posterior wall is related to the inner table which separates it
from the frontal lobe of the brain; its floor forms part of the orbital roof; and
the medial wall is a septum separating the two frontal sinuses. The opening of

Fi^, 11. Lateral wall of right nasal cavity. 1, Frontal sinus; 2, Cell of the agger nasi; 3, Sphenoidal
sinus; 4, Large spheno-ethmoidal cell; S, Anterior ethmoidal ceU.

the frontal sinus is in its floor, and communicates with the middle meatus
through the nasofrontal duct (Fig, 11).
The ethmoid sinuses constitute a cell labyrinth and are present at birth as
prolongations of the nasal mucosa into the lateral mass of the ethmoid bone.
In adult life they vary in number, size and shape, and for clinical purposes
they are classified as anterior or posterior, depending upon whether they
communicate with the middle or the superior meatus. The cell labyrinth lies
between the upper half of the nasal cavity medially and the orbit from which
the cells are separated laterally by the lamina papyracea. The cells abut
antaiorly on the frontal process of the maxilla, and posteriorly they lie
against the sphenoid bone. The anatomical details may be seen in Figs, 11
and 12.
The sphenoid sinus occupies the body of the sphenoid bone, and may be
present at birth as a small indentation of nasal mucosa. The sinus varies
greatly in size in the adult. The lateral wall is contiguous with the internal
carotid artery and the cavernous blood sinus; the roof is related to the frontal
 ANATOMY AND PHYSIOLOGY 11

lobe, the olfactory tract, the optic chiasma and the pituitary gland lying in the
hypophyseal fossa; the floor adjoins the pterygoid canal; while the medial
wall is a septum separating it from its neighbour. The ostium is placed high
up in the cavity of the sinus.
Physiology of the Sinuses. The sinuses are lined by mucous membrane
continuous with that of the nasal cavity through the ostia, but the sinus

Fig. 12. Coronal section through the nasal cavities and maxillary sinuses on the plane of the
ostia of the sinuses (viewed from behind). 1, Left frontal sinus; 2, Left anterior ethmoidal cell; 3,
Olfactory sulcus; 4, Right anterior ethmoidal cells; 5, Right frontal sinus; 6, Ethmoidal bulla; 7,
Hiatus semilunaris; 8, Infundibulum or semilunar groove; 9, Uncinate process; 10, Middle conch^
cell; 11, Middle meatus; 12, Inferior concha; 13, Maxillary sinus; 14, Inferior meatus.

mucosa is thinner. The lining epithelium consists of a low stratified columnar

type containing cilia which move the mucus secreted from the subepithelial
glands towards the ostium.
The function of the sinuses is imperfectly understood although many
theories have been proposed, none of which withstand critical scrutiny. It
has been postulated that they assist in humidification of inspired air, that they
aid vocal resonance, that they act as insulators to protect the base of the
brain from cold air, and that they serve to lighten the bones of the skull.
 CHAPTER 2
CLINICAL EXAMINATION

Good illumination is essential for the examination of the nasal cavities as well
as for that of the pharynx, larynx and ear. The specialist has the benefit of a
bull’s eye lamp whicTTcbncentra!^ the rays of a frosted light bulb. The light is
reflected by a concave forehead mirror through the aperture in which the
examiner conducts his investigation with one eye while the other gives
binocular vision past the side of the mirror. During the examination the
patient sits upright with the lamp close to the left side of his head. Direct
sunlight should be excluded from the room. In other situations, the consulting
room of the general practitioner or the patient’s home, these desirable aids
may be lacking. A forehead mirror may be used to reflect daylight or the light
from a bedside lamp, but the fact that the rays reflected from the mirror are
not concentrated means that the intensity of light is not sufficiently good to

give penetration or to give an accurate impression of mucosal colour. A

small lamp attached to a band around the head and powered by dry batteries
may be sufficient, or the electric auriscope may used with the largest
speculum.
Anterior rhinoscopy is achieved by focusing the light into the nasal cavity to
be examined, and dilating the anterior naris by means of a nasal speculum.
This is not easy to manipulate by the beginner, and the correct method of
holding it is shown in Fig. 13. The blades are apposed and inserted into the
nostril and are allowed to open slowly thus exposing the nasal cavity. The

12
 CLINICAL EXAMINATION 13

anterior end of the inferior concha is immediately seen bulging from the lateral
wall of the cavity. If the concha is large it may obscure the view of the rest of
the nose. In this event the specialist may place a pledget of cotton-wool
soaked in 10 per cent^ocaine hydrochloride against the concha to reduce
the oedema. This may succeed in an allergic swelling, but it may fail if the
enlargement is due to hypertrophy. It must be remembered that some persons
are sensitive to cocaine, and tend to become restless or excited, or with
greater absorption of the drug to become pale and sweating with a rapid
pulse and dilated pupils. In this event they should be advised to place their
head between their knees, or to lie flat.
The nasal septum is easily seen, and should be examined for deviation from
the midline, or dislocation, and the bleeding area should be inspected for
dilated blood vessels in the anastomotic area. If the inferior concha is not
enlarged the olfactory cleft and the middle concha will be seen, and occasion-
ally details of the middle meatus may be inspected.
Examination of the nose, apart from noting septal deflections, should be
directed to the colour of the mucous membrane, the width of airway in the
olfactory cleft, the presence or absence of nasal polypi, and the occurrence
and nature of any secretions.

Fig. 14. Posterior rhinoscopy.

Posterior rhinoscopy is essentially a specialist examination because it

demands a strong light source, and even in such hands it is not invariably
successful because of hypersensitivity of the phaiiynx. It is performed by
depressing the tongue with a spatula and passing a small mirror, angled on a
handle, below the soft palate. The mirror should be heated in the flame of a
spirit lamp so that it does not steam over from the moisture of the breath.
The patient is encouraged to relax and to breathe through his nose. The light
is directed into the mouth and on to the mirror from which it is reflected into
14 THE NOSE AND PARANASAL SINUSES
the nasopharynx, a mirror image of which is seen in the glass. When performed
successfully (Fig. 14), a view is obtained of the posterior end of the nasal
septum, which is seen as a pale vertical ridge. On either side the posterior
nares, or choanae, are seen, and the posterior ends of the three conchae are
visible. Laterally the tubal ridges surrounding the pharyngeal ends of the
auditory tubes come into view. In the roof of the nasopharynx one may see
adenoid tissue, or occasionally a dimpling within a small ridge denotes the
pharyngeal recess (fossa of Rosenmiiller).
Nasopharyngoscopy may be undertaken through an electrical naso-
pharyngoscope which is made on the principle of the cystoscope. It is usually
necessary to anaesthetize the floor of the nose with cocaine before using this,
and, as with all endoscopies, considerable practice and experience are
necessary before the examiner becomes proficient.
In children examination of the nose is easily accomplished by tilting up the
tip of the nose with the thumb and directing the light along the nasal cavities.
Examination of the nasopharynx is not easy without frightening the child,
and should be reserved for the older age group. If it is unsuccessful at the
first attempt it should not be persisted with. The barbarous habit of digital
palpation of the nasopharynx in the conscious child has fortunately been
abandoned. Digital palpation may be performed with ease and accuracy under
anaesthesia when the nature of any swellings may be determined and dealt
with at the same time. Much information regarding the child’s nasopharynx
may be obtained from lateral radiography.